Variation in Payment per Work Relative Value Unit for Breast Reconstruction and Non-breast Microsurgical Reconstruction - An All-Payer Claims Database Analysis

Abstract

Introduction:

Commercial payments for implant-based breast reconstruction have increased within the past decade while reimbursements have stagnated for microsurgical techniques. The physician payment to Work Relative Value Unit(wRVU) ratio allows for standardization when comparing procedures of differing complexity. This study aims to characterize payment-per-RVU for common breast and non-breast microsurgical procedures.

Methods:

The Massachusetts All-Payer Claims Database was queried from 2010–2014 for microsurgical and breast reconstruction related Current Procedural Terminology (CPT) codes. International Classification of Diseases (ICD) codes were further used to categorize procedures by anatomic region including head and neck, breast, trunk, and extremities. Physician payments, for both commercial and governmental, were aggregated by anatomic region and CPT code. Payment distributions were described with means and medians and compared using statistical tests.

Results:

Among 3,435 commercial claims, distributions of physician payments-per-wRVU for microsurgical and common breast procedures differed only for breast free flaps billed through S-Codes(p<0.001). Microsurgical breast procedures(19364) had significantly greater median payments-per-wRVU compared to microsurgery of the head & neck, trunk, upper extremities(p=0.004). Payment-per-wRVU for common breast and non-breast microsurgical procedures did not differ significantly amongst governmental claims(p=0.103).

Conclusion:

Adjustment of physician payments by RVU did not show significant variability across common breast procedures, except for S-Codes, suggesting payments are mostly driven by differences in wRVUs and individual contractual negotiations. Lower payments-per-wRVU for other regions compared to breast suggests an opportunity for negotiation with commercial payers.

Introduction

Trends suggest that commercial payments for implant-based breast reconstruction have increased within the past decade while reimbursements have stagnated for microsurgical techniques(1). A recent analysis demonstrated that relative increases in payments for implant-based reconstruction may influence surgeons to perform this technique (2). Some surgeons have raised concerns that physician payment relative to effort may constrain patients’ ability to undergo autologous reconstruction (2). Given the improved patient-reported outcomes associated with microsurgical breast reconstruction(3, 4), in some scenarios, this may be considered the method associated with greater value(5).

The Specialty Society Relative Value Scale Update Committee (RUC) of the American Medical Association has been meeting for nearly 30 years to assign the work Relative Value Units (wRVU) for all commonly performed procedures within the United States(6). Commercial and public insurers alike use the wRVU scale to determine physician payments. While prior work has demonstrated relative disparities in payments for microsurgical breast reconstruction, no investigation has determined whether or not these payments reflect differences in wRVUs. While wRVUs vary by procedure, the payment per wRVU allows for standardization when comparing procedures of differing complexity. It also remains unknown whether public and commercial payers differ in payments-per-wRVU for breast reconstruction procedures.

The field of microsurgery as performed by plastic surgeons has seen a shift in practice patterns(7), whereby breast operations seem to be gradually expanding while microsurgical reconstructions of the head & neck and extremities subjectively appear unchanged or in relative decline. Despite similar wRVU schedules between different types of microsurgical procedures, there is no evidence regarding whether surgeon payments vary between anatomic region. If differences exist, this could partially explain the growth or decline in rates of microsurgical procedures performed by plastic surgeons in some areas.

This study aims to investigate the payment-per-wRVU ratio for 1) common breast reconstructive procedures, and 2) microsurgical procedures throughout anatomic regions. For aim 1, the hypothesis is that payment-per-wRVU ratios will be greatest for implant reconstruction, while for aim 2, the hypothesis is that payment-per-wRVU ratios will be greatest for microsurgical breast reconstruction.

Methods:

Data Source

Massachusetts all-payer claims data (Mass APCD) were obtained from the Center for Health Information and Analysis. This is a comprehensive claims database of both public and private payers for residents in the state of Massachusetts. Included in this database are individual, patient-level medical, pharmacy, and member eligibility data(8). The database was queried for claims during 2010–2014.

Study Population: Microsurgical Procedures and Anatomic Areas

Mass APCD was queried for microsurgical and breast reconstruction related Current Procedural Terminology (CPT) codes (see Table, Supplemental Digital Content 1, which describes CPT codes and associated work Relative Value Units for microsurgical procedures, INSERT HYPER LINK). International Classification of Diseases (ICD) codes were then used to stratify these microsurgical CPT codes into five different anatomic regions: breast, head & neck, upper extremity, trunk, and lower extremity. Procedures with ICD codes that did not indicate an anatomic region were classified as unknown.

Variables

Commercial payers and governmental payers (Medicare and Medicaid) were described and classified. Physician payments were aggregated by wRVU for each anatomic region (see Table, Supplemental Digital Content 1, which describes CPT codes and associated work Relative Value Units for microsurgical procedures, INSERT HYPER LINK). The current study used wRVUs as published by Specialty Society Relative Value Scale Update Committee (RUC) of the American Medical Association. It is possible that some plans have different wRVU values, however all procedures in this study are captured by CPT codes and all standardized by the same wRVU scale. In this study, S-2068 (breast reconstruction with deep inferior epigastric perforator [DIEP] flap or superficial inferior epigastric artery flap) was attributed the same wRVUs as breast free flap (19364) since in many settings the same procedure is being performed. Physician payments for the breast anatomic region were further evaluated for non-microsurgical procedures as well. All physician payments were adjusted for inflation (see Table, Supplemental Digital Content 2, which describes rates of inflation from 2010 to 2014) and bilateral cases (in the case of breast reconstruction procedures, INSERT HYPER LINK).

Statistical Analysis

The number of claims were tabulated for each anatomic area and for each breast CPT code. Payments-per-wRVU were stratified by payer type (commercial or governmental payer) and differences in payments between anatomic area and breast CPT procedures were further analyzed. Physician payments-per-wRVU were described using the mean (standard deviation [SD]) and the median (interquartile range [IQR]). Differences among anatomic area and breast CPT code were analyzed with Kruskal Wallis test. Pairwise comparisons were analyzed with Mann Whitney test. All statistical tests were two-sided with an alpha of 0.05. All analyses were performed using SQL and R Statistical Software (packages: Tidyverse and Zoo).

Results

Commercial Payer

Breast procedures

A total of 3,435 commercial breast-related claims were analyzed (Table 1, Figure 1). Distributions of physician payments-per-wRVU for microsurgical and non-microsurgical breast procedures (CPT: s2608, 19357, 19367, 19364, 19361) were significantly different from each other (p<0.001). Specifically, s2608 codes had significantly greater median physician payments-per-wRVU ($321.61 [$240.72-$449.51]) than any other code and had the greatest variation, or standard deviation ($238.13), in payments. In an analysis excluding s2608 claims, there was no significant difference in physician payments-per-wRVU (p=0.446) for the remaining breast procedures, although tissue expander procedures (19357) had the greatest median payment ($129.86) while microsurgical 19364 payments had the greatest variation in this subgroup ($121.54 SD: $205.85).

Table 1:

Commercial Payers: Median and Mean Physician Payments-per-wRVU by Breast Procedure

CATEGORY	N	25th percentile	Median	75th percentile	Mean	SD	p value*	p value**
Breast Free Flap s2068	356	240.72	321.61	449.51	380.79	238.13	< 0.001	-
Tissue Expander 19357	2309	102.61	129.86	165.38	139.76	57.80		0.446
TRAM Flap 19367	333	94.57	122.42	153.46	127.04	48.02
Breast Free Flap 19364	103	92.01	121.54	173.84	150.30	205.85
Latissimus Flap 19361	334	89.08	109.29	134.22	114.64	45.64

All values (other than n) are represented as dollars per wRVU; n = number of patients Abbreviations: SD Standard Deviation, TRAM Transverse Rectus Abdominis

^*Kruskal-Wallis comparing commercial payments for all breast groups

^**Kruskal-Wallis comparing commercial payments for all breast groups excluding s2068

Figure 1:

Commercial Payers: Physician Payments-per-wRVU by Breast Procedure

Anatomic Area

A total of 467 commercial claims by anatomic area were analyzed (Table 2, Figure 2). Physician payments-per-wRVU for microsurgery significantly differed among the anatomic areas (p=0.004) with microsurgical breast procedures (19364) having the highest median ($121.54 [$92.01-$2,108.65]) physician payments-per-wRVU. Specifically, 19364 procedures had significantly greater physician payments-per-wRVU than head & neck (p<0.001) and trunk procedures (p=0.002). Head & neck procedures had the second highest median physician payment-per-wRVU ($115.05 [$74.16-$138.64]) whereas trunk procedures had the lowest ($93.48 [$47.15-$120.92]).

Table 2:

Commercial Payers: Median and Mean Physician Payments-per-wRVU for Microsurgery

CATEGORY	N	25th percentile	Median	75th percentile	Mean	SD	p value*	p value**
BREAST (19364)	103	92.01	121.54	173.84	150.30	205.85	0.004	ref
H/N	237	74.16	115.05	138.64	104.10	54.11		< 0.001
LOWER	51	93.99	112.42	142.34	115.51	49.50		0.162
UNKNOWN	31	75.18	112.31	137.88	107.05	65.06		0.066
UPPER	16	94.55	110.02	124.27	124.66	78.43		0.291
TRUNK	29	47.15	93.48	120.92	93.93	59.72		0.002

All values (other than n) are represented as dollars per wRVU; n = number of patients

Abbreviations: H/N Head and Neck, SD Standard Deviation

^*Kruskal-Wallis comparing commercial payments for 19364, H/N, Lower, Trunk, Unknown and Upper

^**Mann-Whitney test comparing to 19364

Figure 2:

Commercial Payers: Physician Payments-per-wRVU for Microsurgery by Anatomic Area

Governmental Payer

Breast procedures

Overall, 712 governmental breast-related claims were analyzed (Table 3, Figure 3). Tissue expander procedures (19357) had the greatest median physician payments-per-wRVU ($56.58 [$42.10-$76.38]) among breast procedures; however, the distributions of physician payments-per-wRVU for breast procedures (CPT: 19357, 19367, 19364, 19361) did not differ significantly from each other (p=0.823). Commercial payers had significantly greater reimbursement compared to governmental payers for all breast procedures (all p < 0.001). There is no governmental correlate for S-codes, so no analysis was performed for s2068.

Table 3:

All Payers: Median and Mean Physician Payments-per-wRVU by Breast Procedure

CATEGORY	Commercial Payers						Governmental Payers							p value **
	N	25th percentile	Median	75th percentile	Mean	SD	N	25th percentile	Median	75th percentile	Mean	SD	p value*
Breast Free Flap s2068	356	240.72	321.61	449.51	380.79	238.13	-	-	-	-	-	-	-	-
Tissue Expander 19357	2309	102.61	129.86	165.38	139.76	57.80	489	42.10	56.58	76.38	59.38	38.11	0.823	< 0.001
TRAM Flap 19367	333	94.57	122.42	153.46	127.04	48.02	79	14.26	46.75	59.43	45.18	27.75		< 0.001
Breast Free Flap 19364	103	92.01	121.54	173.84	150.30	205.85	41	28.69	49.61	68.35	133.01	492.65		< 0.001
Latissimus Flap 19361	334	89.08	109.29	134.22	114.64	45.64	103	37.40	52.38	62.22	51.08	29.30		< 0.001

All values (other than n) are represented as dollars per wRVU; n = number of patients

Abbreviations: SD Standard Deviation, TRAM Transverse Rectus Abdominis

^*Kruskal-Wallis comparing governmental payments for breast procedures

^**Mann Whitney comparing commercial versus governmental payments per category, excluding s2068

Figure 3:

Commercial and Governmental Payers: Physician Payments-per-wRVU by Breast Procedure

Red: Commercial Payments

Blue: Governmental Payments

Anatomic Area

In total, 301 governmental microsurgical claims were analyzed for lower extremity, breast, and head & neck microsurgical procedures (Table 4, Figure 4). When comparing these three groups, lower extremity physician payments-per-wRVU had the highest median reimbursements ($50.65 [$15.79-$62.30]). However, there were no significant differences among the three anatomic areas in physician payments-per-wRVU reimbursed by governmental payers (p=0.103). For lower extremity, head & neck, and breast microsurgical procedures, commercial payers reimbursement significantly more than governmental payers (all p<0.001).

Table 4:

All Payers: Median and Mean Physician Payments-per-wRVU for Microsurgery

CATEGORY	Commercial Payers						Governmental Payers							p value**
	N	25th percentile	Median	75th percentile	Mean	SD	N	25th percentile	Median	75th percentile	Mean	SD	p value*
LOWER	51	93.99	112.42	142.34	115.51	49.50	35	15.79	50.65	62.30	45.85	25.25	0.103	< 0.001
BREAST (19364)	103	92.01	121.54	173.84	150.30	205.85	41	28.69	49.61	68.35	133.01	492.65		< 0.001
H/N	237	74.16	115.05	138.64	104.10	54.11	225	13.28	48.78	61.65	43.24	27.66		< 0.001

All values (other than n) are represented as dollars per wRVU; n = number of patients

Abbreviations: H/N Head and Neck, SD Standard Deviation

^*Kruskal-Wallis comparing governmental payments for microsurgery

^**Mann Whitney comparing commercial versus governmental payments per category

Figure 4:

Commercial and Governmental Payers: Physician Payments-per-wRVU for Microsurgery by Anatomic Area

Red: Commercial Payments

Blue: Governmental Payments

Discussion

For commercial insurers, this study determined that tissue expander breast reconstruction had the highest payment-per-wRVU ratio with a median payment of $129.86/wRVU. This was a greater amount than pedicled TRAM (median $122.42/wRVU) and microsurgical abdominal tissue transfer payments (median $121.54/wRVU). While these findings corroborate prior evidence that microsurgical breast reconstruction does not reimburse on par with tissue expanders(9), the differences in payment-per-wRVU were not statistically significant. Therefore, these findings suggest that the differences in payments between methods of breast reconstruction are largely driven by the differences in wRVUs as well as individual contractual negotiations. For example, 19364 (breast free flap) has greater wRVUs than 19357 so the physician payment would be greater. Prior studies have commented that current wRVU schedules do not adequately capture the time and effort of autologous breast reconstruction(10–13); however, this would have to consider how the effort and complexity of microsurgical breast reconstruction compares to other specialties. For example, microsurgical breast reconstruction is assigned a wRVU of 42.6 while the Whipple procedure (CPT: 48150) carries a wRVU of 52.8(14). These values are determined by the Specialty Society Relative Value Scale Update Committee through member surveys which query the amount of work involved for a service. Interestingly, for commercial payers, the S-2068 code had significantly greater median physician payments-per-wRVU than any other code, which may only be relevant for particular practices. S-codes for level II Healthcare Common Procedure Coding System (HCPCS) indicates that these are private payer codes so there is no applicable governmental correlate. S-codes represent one strategy to improve payments in microsurgical breast reconstruction(11) because they are more specific to the work being performed. Unlike CPT 19364 which is a generic for breast reconstruction with free flap and can include anything from a free TRAM to a DIEP flap, unique S-codes have been established separately for DIEP flaps, SGAPs, as well as stacked flaps. Future potential studies in breast reconstruction would include measurement of operative time per RVU for different procedure types.

Comparing microsurgical breast reconstruction to other microsurgical procedures of the body, breast microsurgery pays more per wRVU. The difference between median breast (highest reimbursed anatomic region) and trunk (lowest reimbursed anatomic region) microsurgical procedures was nearly $30 per wRVU. This amounts to a $1,200 per case payment differential considering many of these microsurgical procedures have an approximate wRVU of 40. Following breast, head & neck procedures were the next highest anatomic region to be reimbursed, although the reimbursement gap was much smaller; median payments differed by $6 per wRVU, translating into $240 for a 40 wRVU case.

Commercial payers showed significant differences in payment-per-wRVU, whereas public payers showed little variation in reimbursements—an expected finding. The wRVU system was originally established for the Centers for Medicare and Medicaid Services as a means to standardize physician payments for Medicare patients. Thus, Medicare and Medicaid adhere to the wRVU payment schedule in reimbursing physicians proportionately per wRVU; however, commercial payers have no obligation to follow RVU scales as seen by the significant variation in payments.

There is no clear explanation for the relatively greater payments-per-wRVU for breast-microsurgery procedures. Breast cancer disease prevalence combined with patient demand for breast reconstruction is one possible explanation for this differential which may be constrained by the limited availability of reconstructive microsurgeons. Thus, commercial payers may compete for reconstructive surgeons in order to meet patient needs and service health system contracts. In contrast, hand and lower extremity microsurgical reconstruction are relatively less frequent operations, usually performed in a more acute setting. The relative urgency and infrequency of these procedures could limit the extent of contractual negotiations. Interestingly, head & neck reconstructive microsurgical operations, which occur somewhat regularly and are often considered more technically challenging than some breast operations, received lesser payments-per-wRVU. One possible explanation for this discrepancy may be a greater pool of surgeons (i.e. less competition) to complete these operations since they can be performed by either plastic or head & neck physicians. There may also be less pressure on commercial markets to make competitive payments to physicians since a large number of head & neck cancer patients are older with Medicare as primary payer. In short, each anatomic area likely has a unique set of circumstances which impact the payments-per-wRVU.

Prior to the passage of the Women’s Health and Cancer Rights Act of 1998, breast reconstruction rates were relatively low and microsurgical breast reconstruction was uncommon. At the time, microsurgery focused on problems in other anatomic areas such as head & neck oncologic reconstruction, complex hand reconstruction and replantation, and lower extremity trauma. Following mandated insurance coverage for post-mastectomy breast reconstruction combined with refinements in technique such as perforator dissection, a significant patient demand for microsurgical breast reconstruction developed. In turn, there has been an increase in the number of microsurgical training programs and trainees (i.e. fellows) along with jobs(15). This can be seen as a good thing for improving patient care as well as increasing the exposure of microsurgery at large. In addition to higher payments, there are other attractive facets to breast reconstruction that could incentivize its practice including case predictability, earlier operative start times, reliability of vascular anatomy (both flap and inset), and better overall medical health of the patient population. Concurrently, declining plastic surgeon involvement in head & neck and hand surgery may be due to a number of reasons. For example, head & neck surgeons control patient flow through the health care system and routinely perform their own microsurgical procedures. Reduced plastic surgeon participation in hand surgeries may reflect other factors including the unpredictable nature of hand trauma. Ultimately, individual microsurgeons will choose their practice area based on intellectual and personal interests, not necessarily influenced by the economic factors investigated in this study. Moreover, the study findings of greater payments-per-wRVU for breast microsurgical procedures could be used by surgeons operating in other anatomic areas to advocate for greater payments in their respective disciplines. Lastly, a recent analysis evaluating whether wRVUs reflect actual operative time has demonstrated a poor correlation for joint replacement(16, 17) raising additional questions about the accuracy of the wRVU system in general(18).

With this study’s strengths, there are also some limitations. This investigation was based on data from the Massachusetts APCD, so results may not be generalizable to the remainder of the US. However, Massachusetts contains the Boston metropolitan area which is the 10^th largest in the country, and the state maintains a variety of commercial payers. As well, some anatomic areas had smaller samples – this study, therefore, reports both mean (SD) and median (IQR) payments to better demonstrate possible bias in the data. Future directions and additional studies could investigate payment variations in other states to evaluate whether physician payments differ significantly by anatomic area. Moreover, the current study may inform health policy efforts to ensure payments-per-wRVU are constant, which is the underlying premise of this system, and were intended to minimize or eliminate health disparities. Data provided herein can be used by physicians to highlight these disparities, and/or to advocate for payment reform through wRVU re-evaluations, albeit within the context of budget neutrality.

Conclusion

Adjustment of physician payments by RVU did not show significant variability across common breast procedures suggesting payments are mostly driven by differences in wRVUs as well as individual contractual negotiations. Rather, the complexity of microsurgical breast procedures may be more adequately captured by HCPCS S-Codes which reflect subtle, but important time intensive aspects of the discipline. Lower payments-per-wRVU for other anatomic regions compared to breast suggest an opportunity for contract negotiation with commercial payers.

Supplementary Material

_1

Table, Supplemental Digital Content 1: Current Procedural Terminology Codes and associated work Relative Value Units for microsurgical procedures .

_2

Table, Supplemental Digital Content 2: United States Rates of Inflation 2010 to 2014.